Melding humans and hi-tech stops ID errors cold

April 2007
Feature Story

Anne Ford

Whenever members of the phlebotomy staff at Ingalls Memorial Hospital, Harvey, Ill., fuss about having to use a new technology—MediCopia, a handheld device from Lattice designed to eliminate patient misidentification and tube mislabeling—the director of laboratory and cardiac services knows how to respond. “When we remind staff that they’ve had no [patient identification] errors since implementation,” says Marilyn Nelson, MBA, MT (ASCP), “it really does stop them in their tracks. It’s something that they’re proud of.”

In the year since Ingalls implemented the Lattice system, not one patient blood sample drawn by the laboratory centralized phlebotomy team has been misidentified. Nelson will discuss her lab’s achievement at the Dark Report’s Executive War College in Miami May 10–11. She and her husband, Keith Nelson, administrative director of laboratory and dialysis, Silver Cross Hospital, Joliet, Ill., will lead a breakout session titled “Integration of Informatics and Automation in Collection, Preanalytical, and Analytical to Eliminate Errors and Boost Both Productivity and Quality.”

Ingalls’ implementation of MediCopia has its roots in site visits and demos that Nelson and other lab staff made to other hospitals before automating their own laboratory. “One of the drawbacks of using an automated system to receive specimens in the lab is the loss of the phlebotomist’s identity,” Nelson says. “The bar-coded tube is loaded and read by the automated processor, which is able to identify the patient, tests ordered, and a time stamp is added before sending the data to the LIS. The inability to identify the collector was of little concern to some of the hospitals we visited while investigating our options.” Many hospitals have myriad workers who collect their specimens. “They felt the collectors’ initials on the tube, for the brief time they were stored before discarding, was sufficient for their needs.”

Nelson wasn’t comfortable with that. “We want as much information about the phlebotomy to be captured in our LIS as possible,” she says. “So everything we capture in Lattice interfaces to [the] Soft [LIS], and [the] StreamLab [workcell] receives it into the laboratory and delivers it to the analyzers. The collection information doesn’t get overwritten. We capture information by phlebotomist, by floor, by time, whatever it is we need to know.”

Of course, technology alone can’t achieve the zero error patient identification rate with laboratory-managed phlebotomists that Ingalls is proud of. It takes much more. “It might be how we enforce its use, or the type of training we give our staff,” Nelson says.

One possibility: “We have project leads and supervisors who are constantly monitoring” the devices’ use, she says. “Right now, the only way one can get a label using the device would be by scanning the [patient] armband.” If a tube came to the lab with a label not generated by the Lattice device but drawn by the lab’s phlebotomy team, questions may be asked: “Why wasn’t Lattice used? Did the patient’s armband not work? Has the nurse been asked to re-band the patient? Are there any IT-related issues going on? It’s the level of accountability, the monitoring, that we haven’t let up on, even after a year.” Additionally, a log of issues is kept and checked daily by her management team so that they and Nelson can determine whether a particular problem is user-, software-, or hardware-related.

Some inpatient phlebotomy staff members were initially resistant to using MediCopia. “Understandably so,” says Nelson. “You’re taking a staff of phlebotomists who never really had to deal with technology.” Many of them were used to just performing the draw, sending it through the laboratory’s pneumatic tube system, and having any IT-related procedures done by someone else.

“So we’ve had to bring some of them up to speed on our LIS,” Nelson says, “which, for those who were avoiding it, was difficult. Some of them loved the change because they like technology and they were excited that phlebotomy was going to take advantage of something new. With experience and exposure, all of the phlebotomists eventually have become proficient.” She’s proud of how well they’ve adapted. “Talk about people who have learned to grow and accept new procedures, new technology, and be successful with it,” she says. “They’re a pretty incredible group.”

The Ingalls lab needed to adjust its workflow to adapt to using the new devices. Since wireless technology is still in the early planning stages at Ingalls, phlebotomists must use docking cradles to upload and download information to their Lattice devices. “In order for that information to be timely,” Nelson says, “they shouldn’t draw more than three or four patients” before docking the device. Docking stations are located on each of the nursing units. “The phlebotomists didn’t like that. They were used to drawing one whole side of the floor and then sending their specimens to the lab. The good thing about the new process is that we’re getting blood in smaller batches, which has improved our workflow. You don’t have bags of blood specimens coming down so many at a time that it creates a bottleneck in our central processing area.”

Of course, as with “any new product or new system, we’ve had a lot of bumps,” Nelson admits. “I can’t say that every single specimen has gone through the process exactly as designed, where one scans a wristband, identifies the patient, and labels print at the bedside. There have been times the server’s been down and we’ve had to resort to manual processes.” But with the staff trained to place so much emphasis on positive patient identification, no errors have been made even during the downtimes.

Downtime procedures did prove to be an implementation hurdle. “I think it was probably the second week we were live,” Nelson says, when “there was a system down and we were forced to admit that we had not adjusted our downtime procedures. ‘What do we do now? How do we get our work?’ In the laboratory you always have a backup plan, but that was one of those pieces we missed. Of course, now, we have good backup procedures.”

Another thing she’d do differently, she adds, is buy more expensive batteries for the Lattice devices. “They only hold a charge for so long, and even though we have extras, and even though we have charging devices,” the current batteries have to be changed out at least once a shift—“and that’s kind of crazy.” For one thing, changing the battery means rebooting the device; “it’s not just popping in a couple of AA batteries,” she points out. The phlebotomists dislike interrupting their workflow to change batteries, but if they don’t, the devices freeze up. So to anyone considering using MediCopia, she suggests, “Don’t cheap out on the batteries.”

Other units at Ingalls are considering adopting the Lattice device, including the admission and discharge center, OB, and the emergency department. All of these areas have their own staff performing the draws. “Our success is something that people kind of want to be a part of,” Nelson says. And now that the laboratory owns the server, software, and licenses, “it’s a much less expensive prospect for additional users. They just need to purchase the hardware.”

One factor that has helped phlebotomists accept the new system is the laboratory’s strict misidentification policy. “Our pathologists had such a strong intolerance” for misidentified specimens, Nelson says, that “we fired people for misdraws. It was our medical director’s stance. We had managers who found it difficult, and it was intimidating to the employees. Lattice fixed the problem for all of us.” When Nelson hears employees expressing frustration about, say, a hardware problem, she reminds them, “Just remember, our patients are safe, you’re not making mistakes, and we’re accomplishing what we need to accomplish.”